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Primary Circumferential Acetabular Labral Reconstruction

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Primary Circumferential Acetabular Labral Reconstruction Primary Circumferential Acetabular Labral Reconstruction Achieving Outcomes Similar to Primary Labral Repair Despite More Challenging Patient Characteristics John P. Scanaliato,* MD, Daniel L. Christensen,y MD, Catherine Salfiti,z BS, Mackenzie M. Herzog,§ MPH, and Andrew B. Wolff,z|| MD Investigation performed at Washington Orthopaedics and Sports Medicine, Washington, DC, USA Background: Treatment of acetabular labral tears with moderate or severe intrasubstance damage or segmental defects remains a substantial challenge. Circumferential labral reconstruction with iliotibial band allograft is a relatively new technique that has been proposed to restore stability and eliminate high-stress junction points. Purpose: To compare outcomes between hips treated with primary allograft circumferential labral reconstruction and primary labral repair. Study Design: Cohort study; Level of evidence, 3. Methods: All consecutive hips between 2014 and 2015 that underwent primary reconstruction or primary repair by the senior surgeon were included and compared. Hips that had a prior intra-articular procedure were excluded. Patient-reported outcome (PRO) scores and visual analog scales were completed by patients within 1 week before surgery and between 22 and 26 months postoperatively. PROs included the modified Harris Hip Score, the International Hip Outcome Tool, and the 12-Item Short Form Health Survey for physical health. Pain and satisfaction were assessed with visual analog scales. Crude and inverse probability of treatment weighting comparisons of PROs between groups were performed. Results: A total of 162 hips met the inclusion criteria for this study, including 99 labral repairs and 63 complete labral reconstruc- tions. Patients who underwent labral reconstruction were, on average, older (43.4 vs 29.5 years; P \ .01), had a slightly higher body mass index (24.6 vs 23.0; P \ .01), had hips with a higher To¨ nnis grade (grade 1 or 2: 25% vs 9%; P \ .01), had higher preoperative pain scores (49.9 vs 41.5; P = .01), and had hips with more severe pathology (68% vs 5%; P \ .01) as compared with patients with labral repair hips. Five (5%) labral repair hips and 5 (8%) labral reconstruction hips failed treatment (P = .48). Among hips that did not fail (n = 94 repairs, n = 58 reconstructions), all demonstrated statistically significant improvements in PROs, and there was no statistical difference in PROs between groups after weighting (P . .05). Conclusion: Primary circumferential labral reconstruction is a viable treatment option with promising short-term outcomes for hips that demonstrate moderate or severe labral damage. Despite less favorable preoperative characteristics, labral reconstruc- tion offers similar outcomes when compared with labral repair in hips with less severe pathology. Keywords: femoroacetabular impingement; labral reconstruction; hip arthroscopy Acetabular labral tears are frequently associated with fem- intrasubstance pathology that are easily treated with repair oroacetabular impingement and can cause significant pain to extensive or complex tears where repair may be difficult and disability.6,31 Treatment of labral tears previously or impossible. included either debridement or labral repair (also described Labral reconstruction has recently been introduced as as labral refixation), with repair typically demonstrating a labral-preserving treatment option for patients with higher function and improved outcomes.8,16,17,22,24 Labral inadequate tissue for repair.33 In the available literature, injury exists on a continuum, from small tears with limited patients with irreparable labral tears or insufficient labral tissue are considered candidates for labral reconstruc- tion.32 Labral reconstruction has led to improvements in symptoms, function, and return to play among elite ath- The American Journal of Sports Medicine letes.2,29 In fact, Domb et al7 demonstrated with a small 1–10 DOI: 10.1177/0363546518775425 cohort that reconstruction was superior to resection, while 19 Ó 2018 The Author(s) Matsuda and Burchette demonstrated that despite more 1 2 Scanaliato et al The American Journal of Sports Medicine significant patient-reported symptoms, reconstruction had The purpose of this study is to compare patient-reported similar outcomes as compared with a repair group. outcomes (PROs) between hips treated with primary allo- Labral reconstruction is hypothesized to restore the nat- graft circumferential labral reconstruction and primary ural biomechanics of the labral suction seal while decreas- labral repair. Secondarily, we assessed the influence of ing pain attributed to resection of the damaged labral tear severity, age, and To¨nnis grade on PROs between tissue—a known pain generator.12 In a cadaveric study, the treatment groups. Our hypothesis was that hips trea- Nepple and colleagues20 and Philippon et al21 found that ted with allograft circumferential labral reconstruction labral reconstruction improves the strength of the labral would have postoperative PROs equivalent to hips treated suction seal, restores stability against distraction to levels with labral repair despite less favorable patient- and hip- similar to those of a native labrum, and restores peak fluid specific preoperative characteristics. pressurization levels to those similar to the intact labrum. Labral reconstruction was also shown to improve the hip joint contact area and contact pressure in an in vitro METHODS model.18 Furthermore, the high level of free nerve ending expression in the labrum suggests that complete resection Patient Population of damaged labral tissue may lead to pain relief.12 Multiple graft options exist for labral reconstruction, All patients scheduled for hip surgery with the senior sur- including autograft iliotibial band, gracilis, semitendino- geon (A.B.W.) are prospectively enrolled in an online out- sus, and ligamentum teres, among others.9,26 However, comes database; these data are collected as standard of there is limited literature on the outcomes of allograft care for all patients. All hips that underwent complete reconstruction.5 Additionally, many labral reconstruction arthroscopic labral reconstruction or arthroscopic labral techniques focus on debridement of the tear back to a stable repair between 2014 and 2015 were selected from the pro- base and creation of a segmental graft that is fixed in this spective outcomes database for inclusion in this study (n = defect. There is concern that the junction points between 210). Patients undergoing a revision procedure were the native labrum and the graft are inherently weak. excluded from this analysis (n = 20). Of the hips that met Shorter segmental reconstruction procedures often posi- the inclusion criteria (n = 190), 4 (2.1%) were excluded tion the junction points between native labrum and graft owing to patient refusal to participate and 24 (12.6%) for in regions of high stress and thus may provide less stability lack of follow-up at postoperative 2 years. The total study or higher risk of breakdown. Furthermore, segmental population comprised 162 hips (85.3% follow-up) among reconstruction techniques may not remove all of the 152 unique patients. This retrospective study was deter- pain-generating tissue and may hinder the ability to per- mined to be exempt from continuing review by the Western form comprehensive pincer-type impingement correction. Institutional Review Board. Circumferential or complete labral reconstruction is per- Indications for hip arthroscopy included hips that had formed by wider excision of the labrum, which eliminates symptoms of sufficient severity and duration to limit desired the labrum-graft interface anteroinferiorly by fixation of activity level and that had failed nonoperative manage- the graft to the acetabulum at the anterior edge of the trans- ment.14 Nonoperative treatment typically spanned a mini- verse acetabular ligament (TAL). Posteriorly, depending on mum of 6 months and consisted of activity modification, the quality of posteroinferior labral tissue, the graft is physical therapy, intra-articular corticosteroid injections, extended either to the TAL or to the 8-o’clock position, and/or nonsteroidal anti-inflammatory medications. Failure where it is fixed to both the labrum and the acetabulum of nonoperative management was defined as continued pain through vertical mattress suture anchor fixation, with the or symptoms despite the aforementioned protocol. Candi- graft abutting the native labrum extra-articularly. dacy for arthroscopic surgery of the hip was further The existing literature has few reports of circumferential assessed by preoperative imaging, which included labral reconstruction with allograft tissue, although White anterior-posterior pelvis, 45° modified Dunn lateral and et al35 demonstrated favorable outcomes at postoperative false-profile view radiographs, and a 3-T magnetic resonance 2 years for patients undergoing labral reconstruction with arthrography.4,13 Treatment of the labrum was determined a similar front-to-back iliotibial band allograft. More intraoperatively: labral tears with mild intrasubstance tear- recently, White et al34 compared 29 patients who underwent ing were repaired, while those with severe intrasubstance primary labral repair on 1 hip and a primary reconstruction damage, labral ossification, or segmental defects were recon- on the other, demonstrating a failure rate of 31% for the structed. In the group with more moderate damage, recon- repair side versus 0% for the reconstruction
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